Why has my husband been given treatment for tuberculosis?

Q: My 32 years old husband had high fever three months back which lasted for ten days. He was diagnosed with a fibrosis in upper right chest with adjacent nodular opacity in a chest x-ray, which suggested a pleural fluid in his right chest. He also got his ADA test done, which was 24.7 IU/L and that too was within normal range. The doctor prescribed AKT - 4 full kit for three months with other tab Omnacortil (10). With this medicine his pleural fluid got reduced but pain is still there. We consulted another doctor for second opinion who totally changed the medicine saying my husband’s ADA is normal. He then prescribed Rcincx (300 Sonaizid +600 Rifampicin) 1 tab, PZA 750 - 2 tabs and Combutal 1000 mg - 1 tab daily empty stomach to be continued for 3 months. But after starting these drugs his pain has increased and now we are in dilemma. What should we do? Doctors are having all different opinion. My husband has lost his appetite and gradually losing his weight. His current weight is 60 kg and height is 5.8 feet. Please advise.

A:Looks like the first physician treated this as Tuberculosis and the second physician has also started treating this as tuberculosis.

The only thing that does not make sense is Omnacortil for the first treatment regimen. It is a corticosteroid (Prednisone) and is not preferred as a treatment for pulmonary tuberculosis. I am not passing judgement on the physician, but this is what I can understand from the supplied information. Suggest avoiding the use of systemic corticosteroids, which are potent immune-suppressants, for the treatment of pulmonary tuberculosis.

The fibrosis in the right upper zone is very suspicious for old healed tuberculosis. However, the nodular opacity is concerning for reactivation tuberculosis but can also happen with any other pneumonia. Therefore it is important to establish the diagnosis of tuberculosis in your husband. The ADA level in your husband's pleural fluid is 25 IU/L. Tuberculosis is rare if the ADA level is less than 40 IU/L.

It is important to screen for other symptoms and signs in him (weight loss, any signs of immune deficiency, cough, etc.). A CT scan of the chest is more sensitive than a chest x-ray to look for other known radiographic manifestations of tuberculosis like cavitary lesions, infiltrates, swollen lymph nodes in the mediastinum, etc.).

It is also important to know other laboratory investigations performed on the pleural fluid (cell count, percentage of lymphocytes, direct acid fast stain looking for tuberculosis organisms, gram stain looking for other organisms).